Use of High PEEP in Shock Patients on Mechanical Ventilation

Hemodynamic Effects of PEEP in Shock

The European Society of Cardiology recommends that shock patients should not routinely receive high PEEP during mechanical ventilation as positive intrathoracic pressure can reduce venous return and worsen right ventricular failure, potentially exacerbating hemodynamic instability 1, 2
Positive intrathoracic pressure induced by mechanical ventilation, particularly high PEEP, can reduce venous return and worsen right ventricular (RV) failure in patients with shock 2
In patients with septic shock, PEEP should be applied with caution to avoid circulatory depression and further hemodynamic compromise, as recommended by the Society of Critical Care Medicine 3, 4
Mechanical ventilation with high PEEP can cause adverse hemodynamic effects that are more prominent in patients with shock due to their already compromised cardiovascular status, according to the European Society of Intensive Care Medicine 5

For sepsis-induced moderate to severe ARDS, the Society of Critical Care Medicine suggests higher PEEP over lower PEEP (weak recommendation, moderate quality evidence) 3, 4
PEEP titration should be done cautiously while monitoring for signs of decreased cardiac output, as recommended by the Society of Critical Care Medicine 7
In pulmonary embolism with shock, PEEP should be applied with extreme caution as it may worsen RV failure, according to the European Society of Cardiology 1, 8

The European Society of Cardiology recommends starting with lower PEEP levels (5-8 cm H₂O) in shock patients 8
If the patient has ARDS, cautiously increase PEEP while monitoring hemodynamic parameters, as recommended by the Society of Critical Care Medicine 3, 4
Consider fluid resuscitation before applying higher PEEP, but avoid aggressive volume loading which can worsen RV function, according to the European Society of Cardiology 9
If vasopressors are required, norepinephrine is preferred as it can improve RV function and coronary perfusion, as recommended by the European Society of Cardiology 8

In pediatric sepsis with PARDS (Pediatric ARDS), higher PEEP is suggested but with careful monitoring for adverse hemodynamic effects, according to the European Society of Intensive Care Medicine 5
For patients with pulmonary embolism and shock, avoid aggressive volume expansion as it may worsen RV function through mechanical overstretch, as recommended by the European Society of Cardiology 9
Recruitment maneuvers, while potentially beneficial for oxygenation, should be used with extreme caution in shock patients due to their potential to cause profound hemodynamic instability, according to the Society of Critical Care Medicine 3, 4